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Showing results for tags 'Human factors'.
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Content ArticleDoes your manufacturing facility experience an undesirable frequency of costly product losses? Are recurring operational issues impacting productivity and morale? Do people believe the causes of these production issues are ‘human error’? Do Quality Differently will show you: How to take a systems-based risk management approach to create more operational success. Practical examples to guide improvement in your operations. Ways to apply comprehensive approaches that reveal and address the combination of factors that influence performance outcomes.
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Content ArticleEnsuring organisations learn from patient safety incidents is a key aim for healthcare organisations. The role that human factors and systems thinking can have to enable organisations learn from incidents is well acknowledged. A systems approach can help organisations focus less on individual fallibility and more on setting up resilient and safe systems. Investigation of incidents has previously been rooted in reductionist methodologies, for example, seeking to find the ‘root cause’ to individual incidents. While healthcare has embraced, in some contexts, the option for system-based methodologies—for example, SEIPS and Accimaps—these methodologies and frameworks still operate from a single incident perspective. It has long been acknowledged that healthcare organisations should focus on near misses and low harms with the same emphasis as incidents resulting in high harm. However, logistically, investigating all incidents in the same way is difficult.
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Content ArticleThis blog by Operations Insider looks at the Gemba Walk approach to problem solving in systems. Gemba Walks involve looking at problems where they occur and discussing them on site, in the real world. The blog includes a series of questions to consider when using the Gemba Walk approach,
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Content Article
What is a Gemba Walk? (SSDSI)
Patient-Safety-Learning posted an article in Improving systems of care
This blog describes the Gemba Walk technique, a popular LEAN management method. During a Gemba Walk, leaders gain valuable insight into the flow of value within the organisation by visiting the workplace and interacting with employees. Leaders also learn new ways to support their employees. The approach encourages collaboration between employees and the leaders. The article covers: What is a Gemba Walk? Three important components of the Gemba Walk Gemba Walk planning, execution and follow-up Get the team ready Develop a plan Follow the Value Stream Never lose sight that the process as a problem (not the people) Keep a record of your observations Ask questions Do not suggest changes during the walk Participate in teams Who should go on a Gemba Walk? Follow up with employees Return to the Gemba An example Gemba Walk Checklist -
Content ArticleTo overcome the problem of development teams losing sight of the detail of processes they are trying to improve, Toyota developed what they call a 'Gemba Walk'. The translation of the term from the root Japanese word is 'the real place' or 'the place where value is created'. This article describes how a Gemba Walk works, how it has been adapted for different industries and the value of engaging both leaders and employees in the process.
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Content Article
The term 'Gemba Walk' is derived from the Japanese word 'Gemba' or 'Gembutsu' which means 'the real place', so it can be literally defined as the act of seeing where the actual work happens. A safety Gemba Walk, or Gemba safety walk, is a safety walk integrated with the Gemba method, emphasising the continuous improvement of safety by watching the actions required to complete daily tasks and determine ways to make work safer. While a typical site safety walk through aims to maintain compliance with safety standards, a safety Gemba Walk focuses on looking for opportunities to continuously improve workplace safety. This article describes the Gemba Walk method and includes information on: What is a Safety Gemba Walk? What is a Virtual Gemba Walk? Why are Gemba Walks important? Benefits How to do a Gemba Walk Process How often should you do a Gemba Walk? Effective ways to do a Gemba Walk Examples -
Content ArticleOn paper, a GP’s working schedule can look quite inviting: consulting for three and a half hours in the morning, with a coffee break in the middle, then a gap for lunch and home visits before a similar length afternoon surgery. However, this is rarely the reality for NHS GPs. In this BMJ opinion piece, GP Helen Salisbury talks about what working life is really like for GPs and highlights the mismatch between their scheduled hours and tasks and the reality, which often involves them doing much more. She highlights how the unrealistic demands GPs face have been exacerbated by a movement of work from secondary to primary care, and argues that this is contributing to the workforce crisis that general practice faces.
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Content Article
NHS Patient Safety Syllabus v. 2.1 (June 2022)
Patient Safety Learning posted an article in Training & education
The Academy of Medical Royal Colleges and the University of Warwick have developed this NHS Patient Safety syllabus to complement it as the basis for education and training for staff throughout the NHS. -
Content Article
Rethinking healthcare as a safety-critical industry
Patient Safety Learning posted an article in Barriers
The discipline of ergonomics, or human factors engineering, has made substantial contributions to both the development of a science of safety, and to the improvement of safety in a wide variety of hazardous industries, including nuclear power, aviation, shipping, energy extraction and refining, military operations, and finance. It is notable that healthcare, which in most advanced societies is a substantial sector of the economy and has been associated with large volumes of potentially preventable morbidity and mortality, has not up to now been viewed as a safety critical industry. This paper from Robert L Wears proposes that improving safety performance in healthcare must involve a re-envisioning of healthcare itself as a safety-critical industry, but one with considerable differences from most engineered safety-critical systems. This has implications both for healthcare, and for conceptions of safety-critical industries. -
Content Article
Breaks from operational duty are an important factor in the management of fatigue. But as highly committed and professional operational staff often perform several secondary tasks and activities—inside or outside the ops room—breaks can become a victim. This blog by Chartered Ergonomist and Human Factors Specialist Stephen Shorrock offers some general guidelines about what kinds of tasks add to stress and fatigue and should be avoided during rest breaks. He places break activities into three categories which place different demands on the individual: red, amber and green activities. He also highlights that when it comes to breaks from operational duty, changes in activity are the key to reducing fatigue-related risks. -
Content ArticleIn this blog, interdisciplinary humanistic, systems and design practitioner Dr Stephen Shorrock explores the dangers of project leaders relying on assumptions about work-as-imagined, detached from the reality of contextualised work-as-done. He describes his experience working on a project in which he discovered that operational staff felt anxious and unprepared for the major changes to come. This was unacknowledged by management, and he ascribes their lack of awareness to a failure to physically and empathetically engage with the workers in the reality of the processes and systems management had designed. He highlights the importance of empathy and asks the question, "In your worlds, how connected are managers and other non-operational specialists with operational staff and the operational environment, where changes ultimately end up? Those who wish to support operational staff through change must take the role of pupil, or apprentice – not master."
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Content ArticleMedical equipment, supplies, and devices (ESD) serve a critical function in healthcare delivery and how they function can have an impact on patient safety. ESD-related safety issues include malfunctions, physically missing ESDs, sterilisation and usability. Describing ESD-related safety issues from a human factors perspective that focuses on user interactions with ESDs can provide additional insights to address these issues. This article in the journal Patient Safety reviewed ESD patient safety event reports submitted to the Pennsylvania Patient Safety Reporting System to identify ESD-related safety issues.
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Content ArticleFailure to rescue is defined as mortality after complications during hospital care. Incidence ranges 10.9%–13.3% and several national reports such as National Confidential Enquiry into Patient Outcomes and Death and National Institute of Clinical Excellence CG 50 highlight failure to rescue as a significant problem for safe patient care. To avoid failure to rescue events, there must be successful escalation of care. Studies indicate that human factors such as situational awareness, team working, communication and a culture promoting safety contribute to avoidance of failure to rescue events. Understanding human factors is essential to developing work systems that mitigate barriers and facilitate prompt escalation of care. This qualitative evidence synthesis identifies and synthesise what is known about the human factors that affect escalation of care.
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Content ArticleAlarms are signals intended to capture and direct human attention to a potential issue that may require monitoring, assessment or intervention. They play a critical safety role in high-risk industries such as healthcare, which relies heavily on auditory and visual alarms. While there are some guidelines to inform alarm design and use, alarm fatigue and other alarm issues are challenges in the healthcare setting. The automotive, aviation, and nuclear industries have used the science of human factors to develop alarm design and use guidelines. This study in the journal Patient Safety aimed to assess whether these guidelines may provide insights for advancing patient safety in healthcare.
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Noradrenaline and tranexamic acid.jpg
Patient Safety Learning posted a gallery image in Medication
Shared with hub by Dr Abigail Clark-Morgan: Images shared of our stocked noradrenaline ampules and tranexamic acid – these have been mixed up and we are looking to stock alternative volumes of noradrenaline to reduce the likelihood of confusion. The incident also highlighted the importance of checking all the ampules drawn up, drawing up your own medications at the point of administration and effective second checking. Part of our immediate response was to label the noradrenaline ampules to make them more obviously different (the purple ampules pictured below).© Healthcare UK
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Bupivacaine alongside sodium choloride.jpg
Patient Safety Learning posted a gallery image in Medication
Bupivacaine solution, a medication used to decrease feeling in a specific area, alongside sodium chloride used as a saline solution. What could go wrong?! Another example of almost identical packaging/labelling. -
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Storage and labelling
Patient Safety Learning posted a gallery image in Miscellaneous
Similar looking boxes, but different drugs, stored together on the shelf. Easy to pick the wrong one up. -
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Bupivacaine and sodium chloride
Patient Safety Learning posted a gallery image in Medication
Do we need a magnifying glass in every anaesthetic room? Only a matter of time until something bad happens... -
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Glyco ampoules.jpg
Patient Safety Learning posted a gallery image in Medication
Can you read this glyco ampoule? Very small writing on the label - difficult to read, especially when in a hurry. -
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Sodium Chloride and paracetamol solution.jpg
Patient Safety Learning posted a gallery image in Medication
These two solutions look very similar. One is paracetamol, the other Sodium Chloride. Example of packaging/labelling contributing to adverse events. -
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Rocuronium bromide and Midazolam
Patient Safety Learning posted a gallery image in Medication
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Why would manufacturers make labelling for rocuronium orange? This is something you wouldn't want to muddle up.- Posted
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Stexerol-D3.jpg
Patient Safety Learning posted a gallery image in Medication
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News ArticleAn external review has been launched at a leading children’s hospital after a series of “never events”. According to local commissioners, a review by the Association for Perioperative Practitioners will look into seven incidents at Alder Hey Children’s Foundation Trust over the last two years. The probe had been delayed by the pandemic and began this month. Great Ormond Street Hospital for Children FT and Sheffield Children’s FT, the two other dedicated children’s trusts in England, reported one and four never events respectively, between April 2018 and July 2020, according to national data. In a statement, Alder Hey claimed it could not provide further details of the incidents. But most have been described in its board papers over the past year. They include a 15-year-old who had the wrong tooth removed by the surgical division, a patient who had the wrong eye operated on, a swab that was left inside a patient having their adenoids and tonsils removed, and an incorrect implant being inserted into an orthopaedics patient. Liverpool Clinical Commissioning’s group’s board papers for September said: “The trust has had a series of seven never events and there is a plan to undertake an external review that has been delayed due to the pandemic response. The trust has approached the Association for Perioperative Practitioners and have agreed the process." “The trust also plans to work with Imperial College London on a peer review and bespoke human factors training to include simulation training and coaching. The trust also plans to produce an overarching action plan to bring together the themes and learning from the seven never events. This work is still underway and NHSE/I and CCG had requested a copy of this plan.” Read full story (paywalled) Source: HSJ, 24 September 2020
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News Article76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019. HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection in relation to medical exposure to ionising radiation in Ireland. In its 2019 report — its first such publication — HIQA expressed hope that the areas of improvement it identified "would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland." Despite this, eight more accidental exposure incidents were recorded in 2020 than in the previous year. Human error was identified as the main cause of accidental exposure in 58% of the incidents, however, HIQA determined that other factors likely contributed to these. Some 34% of the incidents involved the wrong patient being exposed to ionising radiation. HIQA said these exposures occurred at varying points along the medical exposure pathway. It stressed that the number of unintended exposure to ionising radiation incidents last year was small compared with the total number of procedures carried out, estimated to be in the region of three million. Read full story Source: Irish Examiner, 15 September 2021
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Event
Systems approach to patient safety
Patient Safety Learning posted an event in Community Calendar
This one day masterclass is part of a series of masterclasses focusing on how to use Human Factors in your workplace. Leadership in the NHS is the responsibility of all staff. Understanding human factors will allow healthcare to enhance performance, culture and organisation. These masterclasses have been re-designed in line with the new Patient Safety Syllabus. It will look at why things go wrong and how to implement change to prevent it from happening again or mitigate the risks. This masterclass will focus on systems to improve patient safety. For further information and to book your place visit https://www.healthcareconferencesuk.co.uk/conferences-masterclasses/systems-approach-patient-safety-masterclass or click on the title above or email kate@hc-uk.org.uk hub members can receive a 20% discount. Email info@pslhub.org for discount code.
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